BMM 4/7/2016
Davidson County Community College
MEDICAL WITHDRAWAL FORM
Medical Withdrawal Policy:
In order to declare an emergency or medical withdrawal, the student must submit this form to their
Academic Advisor along with a written request and supporting documentation.
The Written Request must include:
the reason for the withdrawal.
an explanation why a complete withdrawal is unnecessary if the student is not requesting to be
withdrawn from all courses.
circumstances causing a delay in the request if grades have been recorded. In this case, the form
needs to be submitted before the last day of the following semester.
The Supporting Documentation must include:
information regarding the emergency situation or medical condition that corresponds with the
reason for the withdrawal request.
verification of the dates of the emergency situation or medical condition that corresponds with the
semester in which the withdrawal is requested.
The Director, Student Records and Registration will approve or deny the request. Appeals of the Director’s
decision must be made in writing to the Vice President, Student Affairs within ten business days of the
date of the original decision. A student who is approved to withdrawal for emergency or medical reasons
will receive a grade of “W” for the course(s). Tuition refunds can only be given for courses officially
dropped prior to the 10% date published in the College’s Academic Calendar.
To be Completed by the Student:
Student ID: Date of Birth:
First Name: Last Name:
Phone: Email:
Semester
(Ex. Fall)
Year
(Ex. 2015)
Course Prefix
(Ex. ENG)
Course Number
(Ex. 111)
Course Section
(Ex. A)
Written Request Attached Supporting Documentation Attached
Student Signature: Date:
Academic Advisor Signature: Date:
************************************************************************************
Date Received: Approved Not Approved
Director, SR&R Signature: Date:
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome